1. The guidelines provide recommendations for managing diabetic foot infections (DFIs). DFIs should be clinically defined by signs of inflammation or purulence and classified by severity. This helps determine treatment approach.
2. Many bacteria can cause DFIs but gram-positive cocci, especially staphylococci, are most common. Infected wounds require antibiotic therapy based on culture results and clinical factors. Imaging helps diagnose osteomyelitis, which can be difficult to treat.
3. Surgical interventions and proper wound care are often needed to successfully cure the infection. A multidisciplinary approach including specialists improves outcomes. Patients require evaluation for ischemia and follow-up.
This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.
Presenter: Dr Yasmin Mohamed Gani, Infectious Disease Physician at Hospital Sungai Buloh, Malaysia.
#dengue #WorldNTDDay #BeatNTDs #BestScienceforAll
This bulletin is a publication of the CRC networks in Perak (Hospital Raja Permaisuri Bainun Ipoh, Hospital Seri Manjung and Hospital Taiping).
This issue emcompasses various research articles written by CRC staff, a research scope write-up to emphasize on the research focus this coming year, programmes conducted in 2021 as well as upcoming events across the CRC Perak Network this year.
(e-ISSN Number: 2682-7867).
This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.
Presenter: Dr Yasmin Mohamed Gani, Infectious Disease Physician at Hospital Sungai Buloh, Malaysia.
#dengue #WorldNTDDay #BeatNTDs #BestScienceforAll
This bulletin is a publication of the CRC networks in Perak (Hospital Raja Permaisuri Bainun Ipoh, Hospital Seri Manjung and Hospital Taiping).
This issue emcompasses various research articles written by CRC staff, a research scope write-up to emphasize on the research focus this coming year, programmes conducted in 2021 as well as upcoming events across the CRC Perak Network this year.
(e-ISSN Number: 2682-7867).
ARV Therapy and the Role of Early Intervention presented by Dr. Rachel Baden, Harvard Medical Faculty Physician at the Fenway Health Center community education conference: An End To AIDS - How A State Bill Can Change Everything hosted by SearchForACure.org, the Fenway Health Center, and the MA Dept. of Public Health
Efficacy and safety of Sulfad tablets in supporting patientswith viral
hepatitis:Aprospective,double-blind,randomized, placebo-controlled,
phase III clinical trial
Wesley Campbell, M.D., of U.S. Navy Medicine, presents "Neurocognitive Changes in Newly Diagnosed Patient with Low CD4: Implications for Prognosis and Employment"
Information about Acute abdomen in covid by Dr Dhaval Mangukiya.
Details of Acute abdomen in covid, Liver Injury, Hypotheses, Gastrointestinal manifestations, Critically ill patients with COVID-19 etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
ARV Therapy and the Role of Early Intervention presented by Dr. Rachel Baden, Harvard Medical Faculty Physician at the Fenway Health Center community education conference: An End To AIDS - How A State Bill Can Change Everything hosted by SearchForACure.org, the Fenway Health Center, and the MA Dept. of Public Health
Efficacy and safety of Sulfad tablets in supporting patientswith viral
hepatitis:Aprospective,double-blind,randomized, placebo-controlled,
phase III clinical trial
Wesley Campbell, M.D., of U.S. Navy Medicine, presents "Neurocognitive Changes in Newly Diagnosed Patient with Low CD4: Implications for Prognosis and Employment"
Information about Acute abdomen in covid by Dr Dhaval Mangukiya.
Details of Acute abdomen in covid, Liver Injury, Hypotheses, Gastrointestinal manifestations, Critically ill patients with COVID-19 etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
ABSTRACT- Diabetic foot infections are the most common problems in persons with diabetes. Among the 50 samples, 43 (86%) showed positive results of bacterial infection. Diabetic foot lesions are divided into six grades based on the depth of the wound and extent of the tissue necrosis. Inci-dences of bacteria were recorded as Staphylococcus aureus (31.37%) followed by Proteus mirabilis (21.05%), Pseudomonas aeruginosa (15.79%), Streptococcus pyogenes (14.04%), Escherichia coli (7.02%), Clostridium botulinum (5.26%), Peptococcus spp. (3.50%) and Salmonella typhimurium (1.75). The prevalence of diabetic foot infections varies according to sex, age, sugar level and economic status. Males were more susceptible to in-fection than females because of higher outdoor activities. Age groups of 40-50 years and fasting sugar levels of 100-150 mg/dl showed maximum incidence of bacterial infection in diabetic foot lesions. Maximum incidences of bacterial infection were found in patients of poor economic status followed by those of middle and high economic status respectively, due to lack of education about the disease and unhygienic surroundings. Except Peptococcus spp. the remaining isolates exhibited Multiple Drug Resistance (MDR). The selection of empiric antibiotic therapy depends on various factors such as infection severity, over all patient condition, medication allergies, previous antibiotic treatment, antibiotic activity, toxicity, excretion and glycemic control. Proper identification of causative agents, appropriate antibiotic therapy and management of complications of diabetic foot in-fections remain essential to the achievement of a successful outcome. Key words: Diabetic foot infection and Multiple Drug Resistance.
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
1. I D S A G U I D E L I N E S
2012 Infectious Diseases Society of America
Clinical Practice Guideline for the Diagnosis
and Treatment of Diabetic Foot Infectionsa
Benjamin A. Lipsky,1
Anthony R. Berendt,2
Paul B. Cornia,3
James C. Pile,4
Edgar J. G. Peters,5
David G. Armstrong,6
H. Gunner Deery,7
John M. Embil,8
Warren S. Joseph,9
Adolf W. Karchmer,10
Michael S. Pinzur,11
and Eric Senneville12
1
Department of Medicine, University of Washington, Veterans Affairs Puget Sound Health Care System, Seattle; 2
Bone Infection Unit, Nuffield
Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford; 3
Department of Medicine, University of Washington, Veteran Affairs Puget Sound
Health Care System, Seattle; 4
Divisions of Hospital Medicine and Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio; 5
Department of
Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands; 6
Southern Arizona Limb Salvage Alliance, Department of Surgery,
University of Arizona, Tucson; 7
Northern Michigan Infectious Diseases, Petoskey; 8
Department of Medicine, University of Manitoba, Winnipeg,
Canada; 9
Division of Podiatric Surgery, Department of Surgery, Roxborough Memorial Hospital, Philadelphia, Pennsylvania; 10
Department of Medicine,
Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; 11
Department of
Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois; and 12
Department of Infectious Diseases, Dron Hospital,
Tourcoing, France
Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs)
typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with
microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence.
Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more
extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification
system, along with a vascular assessment, helps determine which patients should be hospitalized, which may
require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs
are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common
causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic
or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds.
Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected
wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric
antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for
infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually
require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but
magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients
with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat
(often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require
some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds
must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic
foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive
measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organiz-
ations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.
Received 21 March 2012; accepted 22 March 2012.
a
It is important to realize that guidelines cannot always account for individual
variation among patients. They are not intended to supplant physician judgment
with respect to particular patients or special clinical situations. IDSA considers
adherence to these guidelines to be voluntary, with the ultimate determination
regarding their application to be made by the physician in the light of each
patient’s individual circumstances.
Correspondence: Benjamin A. Lipsky, MD, University of Washington, VA Puget
Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108
(balipsky@uw.edu).
Clinical Infectious Diseases 2012;54(12):1679–84
Published by Oxford University Press on behalf of the Infectious Diseases Society of
America 2012.
DOI: 10.1093/cid/cis460
IDSA Guideline for Diabetic Foot Infections • CID 2012:54 (15 June) • 1679
byguestonMay23,2012http://cid.oxfordjournals.org/Downloadedfrom
2. EXECUTIVE SUMMARY
Diabetic foot infections (DFIs) are a frequent clinical problem.
Properly managed, most can be cured, but many patients
needlessly undergo amputations because of improper diagnos-
tic and therapeutic approaches. Infection in foot wounds
should be defined clinically by the presence of inflammation
or purulence, and then classified by severity. This approach
helps clinicians make decisions about which patients to hospi-
talize or to send for imaging procedures or for whom to rec-
ommend surgical interventions. Many organisms, alone or in
combinations, can cause DFI, but gram-positive cocci (GPC),
especially staphylococci, are the most common.
Although clinically uninfected wounds do not require anti-
biotic therapy, infected wounds do. Empiric antibiotic regi-
mens must be based on available clinical and epidemiologic
data, but definitive therapy should be based on cultures of
infected tissue. Imaging is especially helpful when seeking
evidence of underlying osteomyelitis, which is often difficult
to diagnose and treat. Surgical interventions of various types
are often needed and proper wound care is important for
successful cure of the infection and healing of the wound.
Patients with a DFI should be evaluated for an ischemic
foot, and employing multidisciplinary foot teams improves
outcomes.
Summarized below are the recommendations made in the
new guidelines for diabetic foot infections. The expert panel
followed a process used in the development of other Infectious
Diseases Society of America (IDSA) guidelines, which in-
cluded a systematic weighting of the strength of recommen-
dation and quality of evidence using the GRADE (Grading of
Recommendations Assessment, Development and Evaluation)
system [1–6] (Table 1). A detailed description of the methods,
background, and evidence summaries that support each of the
recommendations can be found online in the full text of the
guidelines.
RECOMMENDATIONS FOR MANAGING
DIABETIC FOOT INFECTIONS
I. In which diabetic patients with a foot wound should I suspect
infection, and how should I classify it?
Recommendations
1. Clinicians should consider the possibility of infection oc-
curring in any foot wound in a patient with diabetes (strong,
low). Evidence of infection generally includes classic signs of
inflammation (redness, warmth, swelling, tenderness, or pain)
or purulent secretions, but may also include additional or sec-
ondary signs (eg, nonpurulent secretions, friable or discolored
granulation tissue, undermining of wound edges, foul odor)
(strong, low).
2. Clinicians should be aware of factors that increase the
risk for DFI and especially consider infection when these
factors are present; these include a wound for which the
probe-to-bone (PTB) test is positive; an ulceration present for
>30 days; a history of recurrent foot ulcers; a traumatic foot
wound; the presence of peripheral vascular disease in the af-
fected limb; a previous lower extremity amputation; loss of
protective sensation; the presence of renal insufficiency; or a
history of walking barefoot (strong, low).
3. Clinicians should select and routinely use a validated
classification system, such as that developed by the International
Working Group on the Diabetic Foot (IWGDF) (abbreviated
with the acronym PEDIS) or IDSA (see below), to classify infec-
tions and to help define the mix of types and severity of their
cases and their outcomes (strong, high). The DFI Wound Score
may provide additional quantitative discrimination for research
purposes (weak, low). Other validated diabetic foot classification
schemes have limited value for infection, as they describe only
its presence or absence (moderate, low).
II. How should I assess a diabetic patient presenting with a foot
infection?
Recommendations
4. Clinicians should evaluate a diabetic patient presenting
with a foot wound at 3 levels: the patient as a whole, the af-
fected foot or limb, and the infected wound (strong, low).
5. Clinicians should diagnose infection based on the pres-
ence of at least 2 classic symptoms or signs of inflammation
(erythema, warmth, tenderness, pain, or induration) or puru-
lent secretions. They should then document and classify the
severity of the infection based on its extent and depth and the
presence of any systemic findings of infection (strong, low).
6. We recommend assessing the affected limb and foot for
arterial ischemia (strong, moderate), venous insufficiency,
presence of protective sensation, and biomechanical problems
(strong, low).
7. Clinicians should debride any wound that has necrotic
tissue or surrounding callus; the required procedure may
range from minor to extensive (strong, low).
III. When and from whom should I request a consultation for a
patient with a diabetic foot infection?
Recommendations
8. For both outpatients and inpatients with a DFI, clini-
cians should attempt to provide a well-coordinated approach
by those with expertise in a variety of specialties, preferably by
a multidisciplinary diabetic foot care team (strong, moderate).
Where such a team is not yet available, the primary treating
clinician should try to coordinate care among consulting
specialists.
1680 • CID 2012:54 (15 June) • Lipsky et al
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3. 9. Diabetic foot care teams can include (or should have
ready access to) specialists in various fields; patients with a
DFI may especially benefit from consultation with an infec-
tious disease or clinical microbiology specialist and a surgeon
with experience and interest in managing DFIs (strong, low).
10. Clinicians without adequate training in wound debridement
should seek consultation from those more qualified for this task,
especially when extensive procedures are required (strong, low).
11. If there is clinical or imaging evidence of significant
ischemia in an infected limb, we recommend the clinician
Table 1. Strength of Recommendations and Quality of the Evidence
Strength of
Recommendation and
Quality of Evidence
Clarity of Balance Between
Desirable and Undesirable
Effects
Methodological Quality of Supporting
Evidence (Examples) Implications
Strong recommendation,
high-quality evidence
Desirable effects clearly
outweigh undesirable
effects, or vice versa
Consistent evidence from
well-performed RCTs or
exceptionally strong evidence from
unbiased observational studies
Recommendation can apply to most
patients in most circumstances.
Further research is unlikely to
change our confidence in the
estimate of effect
Strong recommendation,
moderate-quality
evidence
Desirable effects clearly
outweigh undesirable
effects, or vice versa
Evidence from RCTs with important
limitations (inconsistent results,
methodological flaws, indirect, or
imprecise) or exceptionally strong
evidence from unbiased
observational studies
Recommendation can apply to most
patients in most circumstances.
Further research (if performed) is
likely to have an important impact
on our confidence in the estimate
of effect and may change the
estimate
Strong recommendation,
low-quality evidence
Desirable effects clearly
outweigh undesirable
effects, or vice versa
Evidence for at least 1 critical
outcome from observational
studies, RCTs with serious flaws
or indirect evidence
Recommendation may change when
higher-quality evidence becomes
available. Further research (if
performed) is likely to have an
important impact on our
confidence in the estimate of
effect and is likely to change the
estimate
Strong recommendation,
very low-quality
evidence (very rarely
applicable)
Desirable effects clearly
outweigh undesirable
effects, or vice versa
Evidence for at least 1 critical
outcome from unsystematic
clinical observations or very
indirect evidence
Recommendation may change when
higher-quality evidence becomes
available; any estimate of effect for
at least 1 critical outcome is very
uncertain
Weak recommendation,
high-quality evidence
Desirable effects closely
balanced with undesirable
effects
Consistent evidence from well-
performed RCTs or exceptionally
strong evidence from unbiased
observational studies
The best action may differ depending
on circumstances or patients or
societal values. Further research is
unlikely to change our confidence
in the estimate of effect
Weak recommendation,
moderate-quality
evidence
Desirable effects closely
balanced with undesirable
effects
Evidence from RCTs with important
limitations (inconsistent results,
methodological flaws, indirect, or
imprecise) or exceptionally strong
evidence from unbiased
observational studies
Alternative approaches likely to be
better for some patients under
some circumstances. Further
research (if performed) is likely to
have an important impact on our
confidence in the estimate of
effect and may change the
estimate
Weak recommendation,
low-quality evidence
Uncertainty in the estimates
of desirable effects, harms,
and burden; desirable
effects, harms, and burden
may be closely balanced
Evidence for at least 1 critical
outcome from observational
studies, RCTs with serious flaws,
or indirect evidence
Other alternatives may be equally
reasonable. Further research is
very likely to have an important
impact on our confidence in the
estimate of effect and is likely to
change the estimate
Weak recommendation,
very low-quality
evidence
Major uncertainty in the
estimates of desirable
effects, harms, and
burden; desirable effects
may or may not be
balanced with undesirable
effects or may be closely
balanced
Evidence for at least 1 critical
outcome from unsystematic
clinical observations or very
indirect evidence
Other alternatives may be equally
reasonable. Any estimate of effect,
for at least 1 critical outcome, is
very uncertain
Abbreviation: RCT, randomized controlled trial.
IDSA Guideline for Diabetic Foot Infections • CID 2012:54 (15 June) • 1681
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4. consult a vascular surgeon for consideration of revasculariza-
tion (strong, moderate).
12. We recommend that clinicians unfamiliar with pressure
off-loading or special dressing techniques consult foot or
wound care specialists when these are required (strong, low).
13. Providers working in communities with inadequate
access to consultation from specialists might consider devising
systems (eg, telemedicine) to ensure expert input on managing
their patients (strong, low).
IV. Which patients with a diabetic foot infection should I
hospitalize, and what criteria should they meet before I
discharge them?
Recommendations
14. We recommend that all patients with a severe infection,
selected patients with a moderate infection with complicating
features (eg, severe peripheral arterial disease [PAD] or lack of
home support), and any patient unable to comply with the
required outpatient treatment regimen for psychological or
social reasons be hospitalized initially. Patients who do not
meet any of these criteria, but are failing to improve with out-
patient therapy, may also need to be hospitalized (strong, low).
15. We recommend that prior to being discharged, a
patient with a DFI should be clinically stable; have had any
urgently needed surgery performed; have achieved acceptable
glycemic control; be able to manage (on his/her own or with
help) at the designated discharge location; and have a well-
defined plan that includes an appropriate antibiotic regimen
to which he/she will adhere, an off-loading scheme (if
needed), specific wound care instructions, and appropriate
outpatient follow-up (strong, low).
V. When and how should I obtain specimen(s) for culture from a
patient with a diabetic foot wound?
Recommendations
16. For clinically uninfected wounds, we recommend not
collecting a specimen for culture (strong, low).
17. For infected wounds, we recommend that clinicians
send appropriately obtained specimens for culture prior to
starting empiric antibiotic therapy, if possible. Cultures may
be unnecessary for a mild infection in a patient who has not
recently received antibiotic therapy (strong, low).
18. We recommend sending a specimen for culture that is
from deep tissue, obtained by biopsy or curettage after the
wound has been cleansed and debrided. We suggest avoiding
swab specimens, especially of inadequately debrided wounds,
as they provide less accurate results (strong, moderate).
VI. How should I initially select, and when should I modify, an
antibiotic regimen for a diabetic foot infection? (See question
VIII for recommendations for antibiotic treatment of
osteomyelitis)
Recommendations
19. We recommend that clinically uninfected wounds not
be treated with antibiotic therapy (strong, low).
20. We recommend prescribing antibiotic therapy
for all infected wounds, but caution that this is often insuffi-
cient unless combined with appropriate wound care (strong,
low).
21. We recommend that clinicians select an empiric anti-
biotic regimen on the basis of the severity of the infection and
the likely etiologic agent(s) (strong, low).
a. For mild to moderate infections in patients who have
not recently received antibiotic treatment, we suggest
that therapy just targeting aerobic GPC is sufficient (weak,
low).
b. For most severe infections, we recommend starting
broad-spectrum empiric antibiotic therapy, pending
culture results and antibiotic susceptibility data (strong,
low).
c. Empiric therapy directed at Pseudomonas aeruginosa
is usually unnecessary except for patients with risk
factors for true infection with this organism (strong,
low).
d. Consider providing empiric therapy directed against
methicillin-resistant Staphylococcus aureus (MRSA) in a
patient with a prior history of MRSA infection; when the
local prevalence of MRSA colonization or infection is
high; or if the infection is clinically severe (weak, low).
22. We recommend that definitive therapy be based on the
results of an appropriately obtained culture and sensitivity
testing of a wound specimen as well as the patient’s clinical
response to the empiric regimen (strong, low).
23. We suggest basing the route of therapy largely on infec-
tion severity. We prefer parenteral therapy for all severe, and
some moderate, DFIs, at least initially (weak, low), with a
switch to oral agents when the patient is systemically well and
culture results are available. Clinicians can probably use highly
bioavailable oral antibiotics alone in most mild, and in many
moderate, infections and topical therapy for selected mild
superficial infections (strong, moderate).
24. We suggest continuing antibiotic therapy until, but not
beyond, resolution of findings of infection, but not through
complete healing of the wound (weak, low). We suggest an
initial antibiotic course for a soft tissue infection of about 1–2
weeks for mild infections and 2–3 weeks for moderate to
severe infections (weak, low).
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5. VII. When should I consider imaging studies to evaluate
a diabetic foot infection, and which should I select?
Recommendations
25. We recommend that all patients presenting with a new
DFI have plain radiographs of the affected foot to look for
bony abnormalities (deformity, destruction) as well as for
soft tissue gas and radio-opaque foreign bodies (strong,
moderate).
26. We recommend using magnetic resonance imaging
(MRI) as the study of choice for patients who require further
(ie, more sensitive or specific) imaging, particularly when soft
tissue abscess is suspected or the diagnosis of osteomyelitis
remains uncertain (strong, moderate).
27. When MRI is unavailable or contraindicated, clinicians
might consider the combination of a radionuclide bone scan
and a labeled white blood cell scan as the best alternative
(weak, low).
VIII. How should I diagnose and treat osteomyelitis of the foot in
a patient with diabetes?
Recommendations
28. Clinicians should consider osteomyelitis as a potential
complication of any infected, deep, or large foot ulcer,
especially one that is chronic or overlies a bony prominence
(strong, moderate).
29. We suggest doing a PTB test for any DFI with an open
wound. When properly conducted and interpreted, it can help
to diagnose (when the likelihood is high) or exclude (when
the likelihood is low) diabetic foot osteomyelitis (DFO)
(strong, moderate).
30. We suggest obtaining plain radiographs of the foot, but
they have relatively low sensitivity and specificity for confirm-
ing or excluding osteomyelitis (weak, moderate). Clinicians
might consider using serial plain radiographs to diagnose or
monitor suspected DFO (weak, low).
31. For a diagnostic imaging test for DFO, we recommend
using MRI (strong, moderate). However, MRI is not always
necessary for diagnosing or managing DFO (strong, low).
32. If MRI is unavailable or contraindicated, clinicians
might consider a leukocyte or antigranulocyte scan, preferably
combined with a bone scan (weak, moderate). We do not rec-
ommend any other type of nuclear medicine investigations
(weak, moderate).
33. We suggest that the most definitive way to diagnose DFO
is by the combined findings on bone culture and histology
(strong, moderate). When bone is debrided to treat osteomyelitis,
we suggest sending a sample for culture and histology (strong,
low).
34. For patients not undergoing bone debridement, we
suggest that clinicians consider obtaining a diagnostic bone
biopsy when faced with specific circumstances, eg, diagnostic
uncertainty, inadequate culture information, failure of
response to empiric treatment (weak, low).
35. Clinicians can consider using either primarily surgical or
primarily medical strategies for treating DFO in properly selected
patients (weak, moderate). In noncomparative studies each ap-
proach has successfully arrested infection in most patients.
36. When a radical resection leaves no remaining infected
tissue, we suggest prescribing antibiotic therapy for only a
short duration (2–5 days) (weak, low). When there is persist-
ent infected or necrotic bone, we suggest prolonged (≥4
weeks) antibiotic treatment (weak, low).
37. For specifically treating DFO, we do not currently
support using adjunctive treatments such as hyperbaric
oxygen therapy, growth factors (including granulocyte colony-
stimulating factor), maggots (larvae), or topical negative
pressure therapy (eg, vacuum-assisted closure) (weak, low).
IX. In which patients with a diabetic foot infection should
I consider surgical intervention, and what type of procedure
may be appropriate?
Recommendations
38. We suggest that nonsurgical clinicians consider request-
ing an assessment by a surgeon for patients with a moderate
or severe DFI (weak, low).
39. We recommend urgent surgical intervention for most
foot infections accompanied by gas in the deeper tissues, an
abscess, or necrotizing fasciitis, and less urgent surgery for
wounds with substantial nonviable tissue or extensive bone or
joint involvement (strong, low).
40. We recommend involving a vascular surgeon early on
to consider revascularization whenever ischemia complicates a
DFI, but especially in any patient with a critically ischemic
limb (strong, moderate).
41. Although most qualified surgeons can perform an ur-
gently needed debridement or drainage, we recommend that in
DFI cases requiring more complex or reconstructive procedures,
the surgeon should have experience with these problems and
adequate knowledge of the anatomy of the foot (strong, low).
X. What types of wound care techniques and dressings are
appropriate for diabetic foot wounds?
Recommendations
42. Diabetic patients with a foot wound should receive ap-
propriate wound care, which usually consists of the following:
a. Debridement, aimed at removing debris, eschar, and
surrounding callus (strong, moderate). Sharp (or surgi-
cal) methods are generally best (strong, low), but mech-
anical, autolytic, or larval debridement techniques may
be appropriate for some wounds (weak, low).
b. Redistribution of pressure off the wound to the entire
weight-bearing surface of the foot (“off-loading”).
IDSA Guideline for Diabetic Foot Infections • CID 2012:54 (15 June) • 1683
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6. While particularly important for plantar wounds, this
is also necessary to relieve pressure caused by dres-
sings, footwear, or ambulation to any surface of the
wound (strong, high).
c. Selection of dressings that allow for moist wound
healing and control excess exudation. The choice of
dressing should be based on the size, depth, and nature
of the ulcer (eg, dry, exudative, purulent) (strong, low).
43. We do not advocate using topical antimicrobials for
treating most clinically uninfected wounds.
44. No adjunctive therapy has been proven to improve res-
olution of infection, but for selected diabetic foot wounds that
are slow to heal, clinicians might consider using bioengineered
skin equivalents (weak, moderate), growth factors (weak, mod-
erate), granulocyte colony-stimulating factors (weak, moder-
ate), hyperbaric oxygen therapy (strong, moderate), or
negative pressure wound therapy (weak, low).
Notes
Acknowledgments. The panel members thank Drs Thomas File, Mark
Kosinski, and Brad Spellberg for their thoughtful reviews of earlier drafts
of the guideline, and Dr James Horton (IDSA SGPC liaison), Jennifer
Padberg, and Vita Washington for overall guidance and coordination in
all aspects of the development of this guideline.
Financial support. Support for these guidelines was provided by the
Infectious Diseases Society of America.
Potential conflicts of interest. The following list is a reflection of what
has been reported to the IDSA. In order to provide thorough transparency,
the IDSA requires full disclosure of all relationships, regardless of rele-
vancy to the guideline topic. The reader of these guidelines should be
mindful of this when the list of disclosures is reviewed. B. L. has served as
a consultant to Merck, Pfizer, Cubist, Innocoll, TaiGen, KCI, and Dipex-
ium. E. S. has served on the board of and consulted for Novartis. H. G. D.
has served on the speakers’ bureau for Merck and Sanofi. J. P. has served
as a consultant to Pfizer and Ortho McNeil. M. P. has served as a consult-
ant for Orthopedic Implants for Deputy Orthopedics and Small Bone
Innovation. W. J. has served as a consultant for Merck, Pfizer, Cerexa, and
Dipexium and has served on the speakers’ bureaus of Merck and Pfizer. A.
W. K. is on the boards of Pfizer and Merck and the speakers’ bureau for
Astella, and consults for Novartis. All other authors report no potential
conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the
content of the manuscript have been disclosed.
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